The learning curve for a novel, fluoroscopy-based robotic-assisted total hip arthroplasty system

Robotic-assisted total hip arthroplasty utilizing a fluoroscopy-guided system produced similar cup accuracy and precision relative to a computerized tomography-based robotic platform

Robotic assistance for total hip arthroplasty (THA) has been demonstrated to improve accuracy of acetabular cup placement relative to manual, unassisted technique. The purpose of this investigation was to compare the accuracy and precision between a fluoroscopy-based robotic total hip arthroplasty platform (FL-RTHA) and a computerized tomography-based (CT-RTHA) platform. The study included 98 consecutive FL-RTHA and 159 CT-RTHA procedures performed via direct anterior approach (DAA). All cases were performed for a pre-operative diagnosis of osteoarthritis, avascular necrosis, or rheumatoid arthritis. Primary outcome variables included cup implantation accuracy and precision (variance). Implantation accuracy was calculated as the absolute value of the difference between pre-operative target cup angles (inclination and anteversion) and the same post-operative angles. Percentage placement in the Lewinnek safe zone was also measured for both cohorts. The FL-RTHA and CT-RTHA cohorts demonstrated a 1.2° difference in absolute values for cup inclination accuracy (4.6° ± 3.6 vs. 3.4 ± 2.7; p = 0.005), and no difference in absolute values for cup anteversion accuracy (4.7° ± 4.1 vs. 4.6 ± 3.4; p = 0.991). Cohorts demonstrated similar precision for cup inclination and anteversion placement parameters, as well as equivalent Lewinnek safe zone placement. The use of a fluoroscopy-based robotic assistance platform for primary DAA THA resulted in similar accuracy and precision of acetabular cup placement when compared to a CT-based robotic assistance system.

Use of a fluoroscopy-based robotic-assisted total hip arthroplasty system resulted in greater improvements in hip-specific outcome measures at one-year compared to a CT-based robotic-assisted system

BACKGROUND

The purpose of this study was to compare one-year patient reported outcome measures between a novel fluoroscopy-based robotic-assisted (FL-RTHA) system and an existing computerised tomography-based robotic assisted (CT-RTHA) system.

METHODS

A review of 85 consecutive FL-RTHA and 125 consecutive CT-RTHA was conducted. Outcomes included one-year post-operative Veterans RAND-12 (VR-12) Physical (PCS)/Mental (MCS), Hip Disability and Osteoarthritis Outcome (HOOS) Pain/Physical Function (PS)/Joint replacement, and University of California Los Angeles (UCLA) Activity scores.

RESULTS

The FL-RTHA cohort had lower pre-operative VR-12 PCS, HOOS Pain, HOOS-PS, HOOS-JR, and UCLA Activity scores compared with patients in the CT-RTHA cohort. The FL-RTHA cohort reported greater improvements in HOOS-PS scores (-41.54 vs. -36.55; p = 0.028) than the CT-RTHA cohort. Both cohorts experienced similar rates of major post-operative complications, and had similar radiographic outcomes.

CONCLUSIONS

Use of the fluoroscopy-based robotic system resulted in greater improvements in HOOS-PS in one-year relative to the CT-based robotic technique.

Contemporary analysis of the learning curve for robotic-assisted total hip arthroplasty emerging technologies

Robotic assisted (RA) total hip arthroplasty (THA) offers improved acetabular component placement and radiographic outcomes, but inconsistent assessment methods of its learning curves render the evaluation of adopting novel platforms challenging. Therefore, we conducted a systematic review to assess the learning curve associated with RA-THA, both tracking a surgeon's performance across initial cases and comparing their performance to manual THA (M-THA). PubMed, MEDLINE, EBSCOhost, and Google Scholar were searched on June 16, 2023, to identify studies published between January 1, 2000 and June 16, 2023 (PROSPERO registration: CRD42023437339). The query yielded 655 unique articles, which were screened for eligibility. The final analysis included 11 articles, evaluating 1351 THA procedures. Risk of bias was assessed via the Methodological Index for Nonrandomized Studies (MINORS) tool. The mean MINORS score was 21.3 ± 0.9. RA-THA provided immediate improvements in acetabular component placement accuracy and radiographic outcomes compared to M-THA, with little to no experience required to achieve peak proficiency. A modest learning curve (12-17 cases) was associated with operative time, which was elevated compared to M-THA (+ 9-13 min). RA-THA offers immediate advantages to M-THA for component placement accuracy and radiographic outcomes. Surgeons should expect to experience increased operative times, which become less pronounced or equivalent to M-THA after a modest caseload.

Use of a fluoroscopy-based robotic-assisted total hip arthroplasty system produced greater improvements in patient-reported outcomes at one year compared to manual, fluoroscopic-assisted technique

INTRODUCTION

The adoption of new technology should be supported by improvements in patient-reported outcomes (PROMs). The purpose of this study was to assess the one-year PROMs of patients who underwent total hip arthroplasty (THA) using a novel, fluoroscopy-based, robotic-assisted (RA-THA) system when compared to a manual, fluoroscopic-assisted technique (mTHA).

MATERIALS AND METHODS

A review of 91 consecutive mTHA and 85 consecutive RA-THA via a direct anterior approach was conducted. All cases were performed by the same surgeon at the same institution, for a pre-operative diagnosis of osteoarthritis, avascular necrosis, or rheumatoid arthritis. Outcomes included one-year Veterans RAND-12 (VR-12) Physical/Mental, Hip Disability and Osteoarthritis Outcome (HOOS) Pain/Physical Function/Joint Replacement, and University of California Los Angeles (UCLA) Activity scores, as well as the difference between pre-operative and one-year post-operative PROMs.

RESULTS

Patients in the RA-THA cohort had lower pre-operative HOOS-JR scores compared to patients in the mTHA cohort (37.0 vs. 43.1; p = 0.031). Cohorts experienced similar one-year post-operative VR-12, HOOS, and UCLA Activity scores. Patients in the RA-THA cohort experienced greater improvements across all pre- and post-operative HOOS scores compared to patients in the mTHA cohort: Pain (+ 54.7 vs. +42.1; p = 0.009), Physical Function (-41.6 vs. -28.7; p = 0.007), and Joint Replacement (+ 46.6 vs. +33.0; p = 0.002). These differences exceeded minimum clinically important difference (MCID).

CONCLUSIONS

Both manual and robotic cohorts experienced benefit from THA at one-year post-operative. Importantly, the use of a novel, fluoroscopy-based robotic assistance system for primary THA resulted in greater improvements in PROMs at one-year relative to manual technique.

Navigating the learning curve: assessing caseload and comparing outcomes before and after the learning curve of computer-navigated total hip arthroplasty

PURPOSE

Computer-navigated (CN) total hip arthroplasty (THA) offers improved acetabular component placement and radiographic outcomes, but inconsistent assessment methods of its learning curves render the evaluation of adopting a novel platform challenging. Therefore, we conducted a systematic review to assess the learning curve associated with CN-THA, both tracking a surgeon's performance across initial cases and comparing their performance to manual THA (M-THA).

METHODS

A search was conducted using PubMed, MEDLINE, EBSCOhost, and Google Scholar on June 16, 2023 to find research articles published after January 1, 2000 (PROSPERO registration: CRD4202339403) that investigated the learning curve associated with CN-THA. 655 distinct articles were retrieved and subsequently screened for eligibility. In the final analysis, nine publications totaling 847 THAs were evaluated. The Methodological Index for Nonrandomized Studies (MINORS) tool was utilized to evaluate the potential for bias, with the mean MINORS score of 21.3 ± 1.2.

RESULTS

CN-THA showed early advantages to M-THA for component placement accuracy and radiographic outcomes but longer operative times (+ 3- 20 min). There was a learning curve required to achieve peak proficiency in these metrics, though mixed methodologies made the required caseload unclear.

CONCLUSIONS

CN-THA offers immediate advantages to M-THA for component placement accuracy and radiographic outcomes, though CN-THA's advantages become more pronounced with experience. Surgeons should anticipate longer operative times during the learning curve for CN-THA, which lessen following a modest caseload. A more thorough evaluation of novel computer-navigated technologies would be enhanced by adopting a more uniform method of defining learning curves for outcomes of interest. Registration PROSPERO registration of the study protocol: CRD42023394031, 27 June 2023.

Digitalization in orthopaedics: a narrative review

Advances in technology and digital tools like the Internet of Things (IoT), artificial intelligence (AI), and sensors are shaping the field of orthopaedic surgery on all levels, from patient care to research and facilitation of logistic processes. Especially the COVID-19 pandemic, with the associated contact restrictions was an accelerator for the development and introduction of telemedical applications and digital alternatives to classical in-person patient care. Digital applications already used in orthopaedic surgery include telemedical support, online video consultations, monitoring of patients using wearables, smart devices, surgical navigation, robotic-assisted surgery, and applications of artificial intelligence in forms of medical image processing, three-dimensional (3D)-modelling, and simulations. In addition to that immersive technologies like virtual, augmented, and mixed reality are increasingly used in training but also rehabilitative and surgical settings. Digital advances can therefore increase the accessibility, efficiency and capabilities of orthopaedic services and facilitate more data-driven, personalized patient care, strengthening the self-responsibility of patients and supporting interdisciplinary healthcare providers to offer for the optimal care for their patients.

Robotic-assisted total hip arthroplasty utilizing a fluoroscopy-guided system resulted in improved intra-operative efficiency relative to a computerized tomography-based platform

Robotic-assisted total hip arthroplasty (THA) using a computerized-tomography (CT) based workflow increases surgical time relative to traditional manual technique. The purpose of this investigation was to compare the intra-operative efficiencies of two robotic THA systems: a fluoroscopy-based platform (FL-RTHA) and a contemporary, CT-based (CT-RTHA) platform. A review of 107 consecutive FL-RTHA and 159 CT-RTHA primary, direct anterior approach (DAA) THA procedures was conducted. All cases were performed by one of two surgeons operating at the same institution, for a pre-operative diagnosis of osteoarthritis, avascular necrosis, or rheumatoid arthritis. Primary outcome variables included averages and consistencies (variances) for surgical times and operating room (OR) times. A secondary outcome was to quantify the duration of robot-active phases in the FL-RTHA workflow. The FL-RTHA cohort experienced shorter surgical times (38.71 min ± 7.00 vs. 75.33 min ± 11.38; p < 0.001) and OR times (101.35 min ± 12.22 vs. 156.74 min ± 17.79; p < 0.001) compared to the CT-RTHA cohort. Surgical times and OR times were both more consistent in the FL-RTHA cohort compared to the CT-RTHA cohort (p < 0.001). Patients who underwent DAA THA with the assistance of a fluoroscopy-based robotic system experienced shorter and more consistent surgical times and OR times compared to patients who underwent similar DAA THA procedures with a contemporary, CT-based robotic platform.

Improved perioperative narcotic usage patterns in patients undergoing robotic-assisted compared to manual total hip arthroplasty

BACKGROUND

Robot-assisted total hip arthroplasty (RA-THA) improves accuracy in achieving the planned acetabular cup positioning compared to conventional manual THA (mTHA), but optimal dosage for peri-RA-THA and mTHA pain relief remains unclear. This study aimed to compare pain control with opioids between patients undergoing direct anterior approach THA with the use of a novel, fluoroscopic-assisted RA-THA system compared to opioid consumption associated with fluoroscopic-assisted, manual technique.

METHODS

Retrospective cohort analysis was performed on a consecutive series of patients who received mTHA and fluoroscopy-based RA-THA. The average amount of postoperative narcotics in morphine milligram equivalents (MME) given to each cohort was compared, including during the in-hospital and post-discharge periods. Analyses were performed on the overall cohort, as well as stratified by opioid-naïve and opioid-tolerant patients.

RESULTS

The RA-THA cohort had significantly lower total postoperative narcotic use compared to the mTHA cohort (103.7 vs. 127.8 MME; P < 0.05). This difference was similarly seen amongst opioid-tolerant patients (123.6 vs. 181.3 MME; P < 0.05). The RA-THA cohort had lower total in-hospital narcotics use compared to the mTHA cohort (42.3 vs. 66.4 MME; P < 0.05), consistent across opioid-naïve and opioid-tolerant patients. No differences were seen in post-discharge opioid use between groups.

CONCLUSIONS

Fluoroscopy-based RA-THA is associated with lower postoperative opioid use, including during the immediate perioperative period, when compared to manual techniques. This may have importance in rapid recovery protocols and mitigating episode burden of care.